What is the best management plan for a 52-year-old male with uncontrolled hypertension (HTN), symptoms of chest tightness, palpitations, and headaches, and comorbid conditions including obstructive sleep apnea (OSA), benign prostatic hyperplasia (BPH), prediabetes, and anxiety?

Assessment and Plan for 52-Year-Old Male with Uncontrolled Hypertension

Assessment

This patient has resistant hypertension with critical medication non-adherence, pending OSA diagnosis, and multiple cardiovascular risk factors requiring immediate systematic intervention. 1

Key Problems Identified:

1. Uncontrolled Hypertension (BP 171/94 mmHg)

• Patient is on triple therapy (lisinopril 40mg BID, carvedilol 25mg BID, chlorthalidone 25mg daily) but admits to poor medication adherence 1
• HR 52 suggests adequate beta-blockade, but BP remains severely elevated 2
• Symptoms of chest tightness, palpitations, and frontal headaches with nausea are concerning for end-organ effects 1
• OSA is the most common secondary cause of resistant hypertension (64% prevalence) and must be addressed urgently 3

2. Obstructive Sleep Apnea (Pending Sleep Study)

• Sleep study scheduled 01/26 is appropriate, but OSA is strongly associated with resistant hypertension and must be treated aggressively once confirmed 4, 5
• Sleeping only 2-3 hours per day is severely inadequate and likely worsening hypertension 6

3. Medication Adherence Crisis

• This is the primary barrier to BP control and must be addressed before adding more medications 1
• Patient taking melatonin 20mg (excessive dose) suggests desperation for sleep improvement 1

4. BPH with Urinary Hesitancy

• IPSS score of 8 (moderate symptoms) warrants treatment 1
• Previous response to tamsulosin documented 1

5. Anxiety and Work Stress

• Contributing to poor sleep and likely worsening hypertension 6
• Nocturnal awakenings related to work stress 1

---

Plan

1. IMMEDIATE PRIORITY: Address Medication Adherence

Before adding or changing medications, adherence must be optimized through team-based care and systematic follow-up. 1

• Implement team-based care with pharmacy involvement for medication reconciliation and adherence counseling 1
• Simplify regimen: Change lisinopril from BID to once-daily dosing (lisinopril 80mg once daily in AM has equivalent efficacy to 40mg BID and improves adherence) 1
• Consider single-pill combination therapy to reduce pill burden once adherence is established 1
• Schedule follow-up in 2 weeks (not 3 months) to reassess adherence and BP response 1
• Educate patient that non-adherence is the leading cause of uncontrolled BP and increases CVA risk 1

2. Hypertension Management Algorithm

Current regimen analysis:

• Lisinopril 40mg BID (ACE inhibitor) - appropriate dose 1
• Carvedilol 25mg BID (beta-blocker) - appropriate for this patient given HR 52 2
• Chlorthalidone 25mg daily (thiazide-like diuretic) - appropriate 1

Next step if adherence confirmed but BP remains >140/90:

• Add spironolactone 25mg daily as the preferred fourth-line agent for resistant hypertension 1, 7
• Alternative if spironolactone contraindicated: amiloride, doxazosin, or eplerenone 1
• Monitor potassium and creatinine within 1 week of starting spironolactone given concurrent ACE inhibitor use 7

Target BP: <130/80 mmHg (not <140/90) per current guidelines 1, 7

3. Obstructive Sleep Apnea Management

OSA treatment is CRITICAL for BP control in this patient. 4, 5, 3

• Proceed with sleep study on 01/26 as scheduled 3
• Once OSA confirmed, initiate CPAP therapy immediately - this will provide modest BP reduction (typically 5-10 mmHg) but is essential 4
• Beta-blockers (carvedilol) are particularly effective for BP control in OSA patients due to sympathetic hyperactivity, so continue current regimen 4
• ACE inhibitors are also effective in OSA-related hypertension due to RAAS activation 4
• Educate patient that untreated OSA makes hypertension nearly impossible to control 5, 3

4. Sleep Hygiene and Melatonin Management

• Discontinue melatonin 20mg - this is an excessive dose (standard is 0.5-5mg) 1
• Prescribe melatonin 3mg at bedtime for short-term use until OSA is treated 1
• Implement sleep hygiene counseling: consistent sleep schedule, avoid caffeine after 2pm, limit screen time before bed 1
• Trazodone 50mg at bedtime PRN for severe insomnia (maximum 2-3 times per week to avoid dependence) 1

5. BPH Management

• Restart tamsulosin 0.4mg daily given previous symptom relief and moderate IPSS score 1
• Alpha-blockers like tamsulosin can cause orthostatic hypotension - counsel patient to take at bedtime and rise slowly 1
• Monitor PSA in 4 weeks as planned 1
• If ejaculatory dysfunction occurs, switch to alfuzosin 10mg daily 1

6. Anxiety and Stress Management

• Refer to behavioral health for cognitive behavioral therapy - this is more effective long-term than medications alone 1
• Consider low-dose SSRI (sertraline 25-50mg daily) if anxiety significantly impairs function 1
• Avoid benzodiazepines - they worsen OSA and can cause dependence 4
• Trazodone 50mg PRN at bedtime addresses both anxiety and insomnia short-term 1

7. Cardiovascular Risk Reduction

• Continue aspirin 81mg daily for primary prevention given multiple risk factors 2
• Refer to cardiology within 1 month (not waiting 1 year) given uncontrolled HTN, chest tightness, and palpitations 1
• Order repeat EKG today to compare with 07/28/25 baseline given current symptoms 2
• Check lipid panel, HbA1c, basic metabolic panel, and urinalysis to assess for end-organ damage 1

8. Prediabetes Monitoring

• Continue monitoring HbA1c every 3 months as planned (last A1c 5.4% in 06/25) 1
• Reinforce lifestyle modifications: weight loss goal of 5-10%, Mediterranean diet, 150 minutes/week moderate exercise 1

9. Follow-Up Schedule

• 2 weeks: Adherence check, BP recheck, review labs 1
• 4 weeks: PSA check, assess tamsulosin response 1
• Post-sleep study (after 01/26): Initiate CPAP if OSA confirmed 3
• 3 months: Reassess BP control, adjust medications if needed 1
• If BP remains >140/90 on 4 medications with confirmed adherence, refer to hypertension specialist 7

---

Critical Pitfalls to Avoid

• Do not add more antihypertensive medications until adherence is confirmed - this is the most common cause of therapeutic failure 1
• Do not delay OSA treatment - it is likely the primary driver of resistant hypertension in this patient 3
• Do not use excessive melatonin doses - 20mg is far above therapeutic range 1
• Do not ignore chest tightness and palpitations - these require urgent cardiology evaluation to rule out ischemia 2
• Monitor for hyperkalemia when combining ACE inhibitor + spironolactone - check potassium within 1 week 7
• Do not prescribe benzodiazepines for anxiety - they worsen OSA 4